NR 508 Chamberlain College of Nursing – Maria is a 46-year-old woman who presents for her yearly physical examination. Her medical history is notable for borderline hypertension and moderate obesity.

Maria is a 46-year-old woman who presents for her yearly physical examination. Her medical history is notable for borderline hypertension and moderate obesity. Six months ago her fasting lipid profile was normal. Maria report that her mother and brother have diabetes and hypertension. She reports that she knows she should be on a low calorie, low fat diet and exercising but with her full time job and four children, she finds it difficult to exercise, and she eats out most of the time. She is 66″ tall and weighs 219lbs today, no current medication. She does report taking a multivitamin, biotin Vit-C when she remembers. She is a nonsmoker, only drinks sweet tea with each meal, 3-4 cups of coffee per day.

Today: BP 155/95mm Hg, TC 234 mg/dL, LDL 137 mg/dL, HDL 35 mg/dL, triglycerides 241mg/dL, fasting plasma glucose is 179 mg/dL; HgbA1C is 7.4mg/dL. Physical Exam reveals notable for acanthosis nigricans at the neck but otherwise is normal.

• What are your treatment goals for Maria?
• What is your plan for drug therapy? What is the mechanism of action for each drug?
• Please give five teaching points for each drug prescribed.

ANSWER

Comprehensive Treatment Approach for Hypertension, Dyslipidemia, and Diabetes in a Busy Lifestyle: A Case Study of Maria

Treatment Goals for Maria

Reduce Blood Pressure: The goal is to lower Maria’s blood pressure to a target of less than 130/80 mm Hg, considering her borderline hypertension and family history of hypertension.

Improve Lipid Profile: The aim is to decrease Maria’s total cholesterol (TC) to below 200 mg/dL, LDL cholesterol to less than 100 mg/dL, and increase her HDL cholesterol to greater than 50 mg/dL (Jiménez et al., 2020). This is crucial in reducing her risk of cardiovascular disease.

Glycemic Control: Given Maria’s elevated fasting plasma glucose and HbA1c levels, the objective is to achieve glycemic control and maintain her HbA1c level below 7% (Sherwani et al., 2016). This will help prevent complications associated with diabetes.

Weight Management: Considering Maria’s moderate obesity, the goal is to encourage weight loss and achieve a healthy body weight. This will positively impact her blood pressure, lipid profile, and glycemic control.

Lifestyle Modifications: It is essential to educate Maria about the importance of dietary modifications, regular exercise, and healthy lifestyle habits. These changes will support her overall treatment goals and long-term health.

Plan for Drug Therapy

Based on Maria’s medical history, family history, and current presentation, the following drug therapy plan is recommended:

Antihypertensive Medication

Maria’s elevated blood pressure warrants the initiation of antihypertensive therapy. A suitable choice would be an angiotensin-converting enzyme (ACE) inhibitor, such as Lisinopril. ACE inhibitors block the conversion of angiotensin I to angiotensin II, leading to vasodilation and reduced blood pressure.

Teaching points for Lisinopril

Take the medication as prescribed, usually once daily, with or without food.

Monitor blood pressure regularly and report any symptoms like dizziness or lightheadedness.

Notify the healthcare provider if any signs of angioedema (swelling of face, lips, tongue, or throat) occur.

Limit alcohol consumption as it may potentiate the blood pressure-lowering effect of Lisinopril.

Report any changes in kidney function, as Lisinopril may affect renal function.

Statin Medication

 Maria’s elevated LDL cholesterol and total cholesterol levels indicate the need for lipid-lowering therapy. A statin, such as Atorvastatin, can be initiated to reduce cholesterol synthesis and promote LDL clearance from the bloodstream.

Teaching points for Atorvastatin

Take the medication as prescribed, usually once daily, with or without food.

Follow a low-fat diet and maintain a healthy lifestyle to optimize the medication’s effectiveness.

Report any symptoms of muscle pain, tenderness, or weakness to the healthcare provider.

Inform the healthcare provider of any new medications to avoid potential drug interactions.

Routine monitoring of liver function tests may be required; discuss with the healthcare provider.

Antidiabetic Medication

Maria’s elevated fasting plasma glucose and HbA1c levels indicate the need for antidiabetic therapy. Metformin, a biguanide, is an appropriate initial choice to improve glycemic control.

Teaching points for Metformin:

Take the medication as prescribed, usually with meals, to minimize gastrointestinal side effects.

Monitor blood glucose regularly and report any signs of hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar).

Maintain a balanced diet and engage in regular physical activity to enhance the medication’s effectiveness (Tuso, 2015).

Inform the healthcare provider if experiencing any significant side effects, such as lactic acidosis symptoms (muscle pain, weakness, difficulty breathing).

Avoid excessive alcohol consumption, as it can increase the risk of lactic acidosis.

Nutritional Counseling

Given Maria’s difficulty with diet control and eating out frequently, a referral to a registered dietitian or nutritionist is essential. They can provide personalized guidance on low-calorie, low-fat meal choices, portion control, and healthy eating habits.

Teaching points for Nutritional Counseling:

Understand the importance of balanced meals, including fruits, vegetables, lean proteins, and whole grains.

Learn about portion control and mindful eating techniques to avoid overeating.

Make informed choices when eating out, such as selecting grilled or steamed options instead of fried foods.

Limit the intake of sugary beverages like sweet tea and replace them with water or unsweetened alternatives.

Maintain a food diary to track daily intake and identify areas for improvement.

Lifestyle Modifications

Emphasize the significance of regular physical activity and stress management techniques in Maria’s treatment plan.

Teaching points for Lifestyle Modifications:

Engage in at least 150 minutes of moderate-intensity aerobic exercise or 75 minutes of vigorous exercise per week.

Choose activities that are enjoyable and fit into her schedule, such as brisk walking, dancing, or cycling.

Involve the family in physical activities to promote a healthy lifestyle for everyone.

Practice stress reduction techniques like deep breathing, meditation, or yoga to manage daily stressors.

Prioritize sleep hygiene and aim for adequate rest to support overall well-being.

By addressing Maria’s hypertension, dyslipidemia, and diabetes with appropriate medication and implementing lifestyle modifications, the treatment plan aims to improve her overall health, reduce the risk of complications, and promote long-term well-being. Regular follow-up visits will be crucial to monitor her progress, adjust medications if necessary, and provide ongoing education and support.

References 

Jiménez, J. B., Carbajo, M. a. M., López, M. G. V., Cao, M., Ruiz-Tovar, J., García, S. M., & Castro, M. A. (2020). Changes in Lipid Profile, Body Weight Variables and Cardiovascular Risk in Obese Patients Undergoing One-Anastomosis Gastric Bypass. International Journal of Environmental Research and Public Health, 17(16), 5858. https://doi.org/10.3390/ijerph17165858 

Sherwani, S. I., Khan, H. A., Ekhzaimy, A., Benabdelkamel, H., & Sakharkar, M. K. (2016). Significance of HbA1c Test in Diagnosis and Prognosis of Diabetic Patients. Biomarker Insights, 11, BMI.S38440. https://doi.org/10.4137/bmi.s38440 

Tuso, P. (2015). Strategies to Increase Physical Activity. The Permanente Journal, 19(4), 84–88. https://doi.org/10.7812/tpp/14-242